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ORANGE COUNTY-DEPARTMENT USE ONLY <br /> Department <br /> Party/Vendor Name : UNC Department of Family Medicine Party/Vendor Contact Person : Sherri Hay Contact <br /> Phone : 984-9744892 Party/Vendor Address : 590 Manning Drive City Chapel Hill State : NC Zip : 2759 <br /> Department: Health Amount : $9, 365 Purpose : Community Health Grant Subcontract Budget Code(s) : 10414020- <br /> 630000=71424 Vendor # 21243 (NIA if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type : <br /> ( Check one) New ❑ Renewal ® Amendment ❑ Effective Date 7/ 1 / 18 Approved by Board Yes ❑ No❑ <br /> Agenda Date . <br /> r <br /> This agreement is approved as to technical form and copYt nt : <br /> 01 <br /> Department Director 's Signature asI I otiti A i A 0jate : <br /> Information Technologies <br /> (Applicable only to hard►vare/sojhvare purchases or related services) This agreement has been reviewed and is <br /> approved as to information technology content and specifications : <br /> Office of the Chief Information Officer Date : <br /> Risk Management <br /> This agreement is approved for sufficiency of insurance standards , specifications , and requirements : <br /> Office of the Risk Management Officer -� l Date : � <br /> Finanki ! l iervices <br /> This instrument has been pre- audited in the m n er re i by the Local Government Budget nd Fi al Control Act: <br /> Office of the Chief Financial Officer Date: Z3 <br /> 1170 <br /> Leaal Services <br /> This agreement is approved as to legal form and sufficiency : <br /> Office of the County Attorney i L L 1:C _Date : I 4 41 l <br /> Clerk to the Board <br /> Received for record retention : <br /> All Docusign contracts must be copied to Sherri Ingersoll upon completion @ Singersol orangecounlync . pgov <br /> The following signature block is for hard copies only and is not required for Docusign contracts : <br /> Office of the Clerk to the Board Date : <br /> Revised 7/ 18 4 <br />